Policy: Gender Affirmation Surgery
Policy Number: 02-55900-01
Last Update: 2021-02-26
Issued in: Florida

This policy applies to Medicare

Breast Reconstruction:

Breast augmentation (implants/lipofilling) for male to female members meets the definition of medical necessity when ALL of the following are met:

A. Member is 18 years or older

B. Member has the capacity to make a fully informed decision and to consent for treatment

C. Documentation shows persistent and well documented gender dysphoria

D. No medical contraindications to surgery

E. Any mental health concerns are well controlled

F. Documentation of 12 continuous months of hormone therapy (unless the member has a medical contraindication or is otherwise unable to take hormones); AND G. One referral letter from a licensed mental health professional.

Youth Services:

Must be 18 or older.